What You Need to Know
Medicare Advantage plans include everything Original Medicare covers.
There are 11 Medicare Advantage plans to choose from in the District of Columbia.
Unlike Original Medicare, Medicare Advantage caps your annual out-of-pocket expenses for healthcare.
Is it time to think about Medicare? If you’re considering your health insurance options in Washington, D.C., a Medicare Advantage (MA) plan may be right for you.
Medicare Advantage, also known as Part C, covers everything that Original Medicare does. In addition to Medicare Part A and Part B, most MA plans offer additional benefits and cap annual out-of-pocket costs.
What Types of Medicare Advantage Plans Are Available?
Health Maintenance Organization (HMO) plans offer lower premiums compared to other plans. You can only go to providers in the network, except for emergencies. And you need a referral from your primary care provider to see a specialist.
Preferred Provider Organization (PPO) plans have more flexibility. You can go to out-of-network providers, but you pay more when you do so. You don’t need a referral to see a specialist.
Special Needs Plans (SNPs) tailor care for individuals with specific needs, including:
- Those with chronic health conditions (C-SNP),
- Dual eligibility for Medicare and Medicaid (D-SNP),
- Those requiring institutional care in skilled nursing facilities or other types of long-term care (I-SNP).
Private Fee-For-Service (PFFS) plans choose how much the plan will pay healthcare providers and how much you will pay out of pocket. You can go to any Medicare-approved provider that accepts the plan’s payment terms and agrees to treat you. Not all providers will.
Medicare Savings Accounts (MSAs) are high-deductible plans combined with a medical savings account. The plan deposits money into a bank account. You use these funds to pay for medical services before you meet your deductible. Once met, your plan pays covered expenses.
Consider all costs
You can get a zero-premium plan with Medicare Advantage, but you may pay more out of pocket when you need care.
What Are Prescription Drug Options with Medicare Advantage?
Your options depend on your plan.
- All SNPs provide prescription drug coverage.
- Most Medicare Advantage HMO and PPO plans include prescription drug coverage, known as Medicare Part D.1 But if your HMO or PPO plan doesn’t, you can’t enroll in a separate Part D plan.
- You can enroll in a Part D plan if you have a PFFS or MSA plan.
How Do You Choose Medicare Advantage Plans?
Cost and coverage are key factors in choosing any health insurance plan. Be sure to consider premium costs, other costs, and plan benefits.
Your premium is the amount you pay each month for the plan. In D.C, you can choose a zero-premium plan. While these plans sound like they’re free, you will still be responsible for the Medicare Part B premium. You may also have a higher deductible and other out-of-pocket costs with a zero-premium plan.
- Coinsurance is a percentage of the cost for services you pay once you meet your deductible.
- Copayments are fixed amounts you pay for office visits and/or prescription drugs.
- Deductible is the amount you must spend before your plan starts to contribute toward your healthcare expenses.
- Out-of-pocket maximum is the highest amount you’re required to pay during the plan year.
Medicare Advantage plans often provide benefits that Original Medicare does not. These may include coverage for vision, dental, hearing, transportation, and telehealth services. Some even include access to gyms or fitness programs.
Medicare Advantage plans usually include benefits not included in Original Medicare.
When and How to Enroll in Medicare Advantage
You must enroll in Medicare Part A and B before you can enroll in an MA plan. Choose the appropriate enrollment period.
Initial Enrollment Period: The seven-month period beginning three months before, the month of, and the three months after your 65th birthday.
Open Enrollment Period (Annual Election Period): October 15 through December 7 annually. You can change MA plans, switch between MA and Original Medicare plans, and enroll in a Part D plan.
General Enrollment Period: January 1 through March 31 annually with coverage beginning July 1.
Medicare Advantage Open Enrollment Period: If you enrolled in Medicare during the General Enrollment Period, you may enroll in an MA plan from April through June with coverage beginning July 1.
Special Enrollment Period: Under certain circumstances, you may be able to enroll outside the scheduled periods without incurring a penalty:
- Change of service area – includes moving out of the provider network.
- Loss of coverage – such as losing coverage under Medicaid or an employer’s plan.
- Gain coverage – such as qualifying for group coverage under an employer or union plan.
- Plan changes – if your plan’s contract is terminated by Medicare.
- Special circumstances – such as development of a chronic condition which qualifies you for a C-SNP.
What’s the Medicare Advantage Enrollment in the District of Columbia?
As of April 2021, there were 23,478 people enrolled in MA plans in the District of Columbia. That represents 24.84% of all Medicare-eligible individuals.2
How Much Do Medicare Advantage Plans Cost in the District of Columbia?
There are currently 11 MA plans offered in the District of Columbia, including HMOs, PPOs, and MSA plans. Monthly premiums range from zero to $142, not including the Part B premium.3 Most people pay $148.50 a month for Part B, though higher-income seniors may pay more.4
As an example, if you enroll in an HMO plan with a $30 premium, you pay that amount, plus the Part B premium for a total monthly payment of $178.50. You pay some additional costs when you get care.
How Do You Change Your Medicare Advantage Plan?
If you’re already enrolled in Medicare Advantage, you can make a change during Open Enrollment or General Enrollment periods. You can switch to a different MA plan or drop your MA plan and join Original Medicare.
What Are Alternatives to Medicare Advantage?
- Original Medicare, which includes Part A and B only. Many people who choose this option also enroll in a Medicare Part D plan to pay for prescriptions. If you go this route, you may also want to purchase a Medigap policy from an insurer to pay for uncovered expenses.
- Program of All-Inclusive Care for the Elderly (PACE) is under development in the District of Columbia. This program integrates Medicare and Medicaid, and helps people meet their healthcare needs in their community instead of going to a nursing home.5
Medicare Advantage plans are similar to Original Medicare with a Medigap policy and a Part D plan, but there are differences. One advantage to MA plans is that they bundle all policies, eliminating the need to manage multiple plans.
What Are Medicare Resources in the District of Columbia?
DC Department of Insurance – provides information about health insurance rights and grievance processes
Medicaid (Medicare Savings Program) Qualified Medicare Beneficiary Program – provides information regarding assistance available to pay for Medicare plans.
State Health Insurance Assistance Program (SHIP) – provides free information and assistance to help you choose Medicare coverage.
Now that you’ve done your homework about Medicare Advantage, it’s time to compare plans available in the District of Columbia. Speak with a licensed professional to explore options. You can also use the Medicare Plan Finder to determine which plan suits your needs and budget.